By Counterforce Health Team in Revlimid (lenalidomide) —

Get Revlimid (Lenalidomide) Covered by Cigna in Florida: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Revlimid (Lenalidomide) Covered by Cigna in Florida

Yes, Cigna covers Revlimid (lenalidomide) for FDA-approved indications with prior authorization (PA). Your oncologist submits the PA via CignaForHCP.com with clinical documentation, REMS compliance proof, and diagnosis codes. Standard review takes 30 days (72 hours if expedited). If denied, you have 180 days to file an internal appeal, followed by free external review through Florida's Department of Financial Services.

First step today: Contact your oncologist's office to confirm they've submitted your PA with complete documentation including prior therapy failures, lab results, and REMS enrollment verification.

Table of Contents

Coverage Basics: Is Revlimid Covered by Cigna?

Revlimid (lenalidomide) is covered by Cigna under their specialty drug formulary for FDA-approved indications, but requires prior authorization for all patients. The drug is typically managed through Express Scripts/Accredo specialty pharmacy and classified as a high-tier specialty medication.

Covered Indications

According to Cigna's oncology policy, Revlimid is covered for:

  • Multiple Myeloma: Newly diagnosed (with bortezomib/dexamethasone or melphalan/prednisone) and relapsed/refractory cases
  • Myelodysplastic Syndromes (MDS): With del(5q) deletion
  • Mantle Cell Lymphoma: Relapsed/refractory after bortezomib
  • Follicular Lymphoma: With rituximab or after prior regimens
  • Marginal Zone Lymphoma: With rituximab or after prior therapy

Which Cigna Plans Cover Revlimid?

Most Cigna plans include Revlimid on their formulary, including:

  • Commercial PPO and HMO plans
  • Medicare Advantage plans (through Express Scripts)
  • Some employer-sponsored plans

Check your specific formulary at myCigna.com or call the number on your insurance card.

Prior Authorization Process: Who Submits and How

Step-by-Step: Fastest Path to Approval

  1. Oncologist Initiates PA (Day 1)
  2. Clinical Documentation Required (Days 1-2)
    • ICD-10 diagnosis codes
    • Prior therapy history with failure reasons
    • Lab results (CBC, metabolic panel)
    • Treatment plan and dosing
  3. REMS Compliance Verification (Ongoing)
    • Prescriber certification in Revlimid REMS program
    • Patient enrollment and signed agreements
    • Pregnancy testing documentation (if applicable)
  4. Cigna Review Process (Days 3-30)
    • Medical necessity evaluation
    • Criteria matching against policy
    • Possible peer-to-peer review request
  5. Decision Notification (Day 30 or sooner)
    • Approval: Prescription sent to specialty pharmacy
    • Denial: Written explanation with appeal rights
Tip: Request expedited review (72-hour decision) if treatment is urgent or ongoing. Your oncologist must justify the urgent need.

Timing: How Long Does Approval Take?

Review Type Timeline When to Use
Standard PA 30 calendar days New diagnoses, maintenance therapy
Expedited PA 72 hours Urgent medical need, treatment delays
Appeal Review 30-60 days After denial
External Review 45 days After internal appeal failure

Coverage Criteria: What Cigna Requires

Medical Necessity Requirements

Based on Cigna's policy, approval requires:

General Criteria (All Patients):

  • Age ≥18 years (unless specified for pediatric use)
  • FDA-approved indication or NCCN-supported off-label use
  • REMS program compliance
  • Adequate baseline lab values

Condition-Specific Requirements:

Indication Prior Therapy Required Lab Requirements
Multiple Myeloma (R/R) ≥1 prior therapy (e.g., bortezomib) CBC, beta-2 microglobulin
Mantle Cell Lymphoma Prior bortezomib or ≥1 regimen Staging studies, CBC
MDS ESA failure or del(5q) confirmation Cytogenetics, transfusion history

Laboratory Monitoring

Cigna requires ongoing monitoring per FDA labeling:

  • Weekly CBC for first 2 cycles (multiple myeloma)
  • Weekly CBC for 8 weeks (MDS)
  • Kidney and liver function tests
  • Pregnancy testing (females of reproductive potential)

Costs and Financial Support

Typical Out-of-Pocket Costs

Revlimid costs over $15,000 per cycle without insurance. With Cigna coverage:

  • Copay plans: $50-$200 per month (varies by tier)
  • Coinsurance plans: 10-30% of drug cost
  • Deductible plans: Full cost until deductible met

Financial Assistance Programs

Bristol Myers Squibb Co-Pay Program:

Independent Foundations:

  • Health Well Foundation: 1-800-675-8416
  • Patient Access Network: Online applications
  • Leukemia & Lymphoma Society: Disease-specific funds

Denials and Appeals: Your Rights in Florida

Common Denial Reasons and Solutions

Denial Reason How to Fix
Incomplete REMS documentation Submit prescriber certification and patient agreements
Insufficient prior therapy Provide detailed history of failed treatments with dates
Off-label use without guidelines Include NCCN or other guideline citations
Missing lab results Submit CBC, metabolic panel within 30 days

Your Appeal Rights in Florida

Florida law guarantees your right to challenge insurance denials through multiple levels of review.

Appeals Playbook for Florida Residents

Internal Appeals (First Step)

Timeline: 180 days from denial notice to file; 30-60 days for decision

How to Submit:

  1. Call Cigna Customer Service: 1-800-882-4462
  2. Submit written appeal using Cigna's appeal form
  3. Include all supporting documentation

Required Documents:

  • Original denial letter
  • Physician letter explaining medical necessity
  • Clinical notes and lab results
  • Treatment guidelines (NCCN, FDA labeling)

External Review (Second Step)

If Cigna upholds the denial, Florida provides free external review through independent medical experts.

How to Request:

  • Contact Florida Department of Financial Services: 1-877-693-5236
  • Submit request within 4 months of final internal denial
  • No cost to you

Timeline: 45 days for standard review, 72 hours for urgent cases

From Our Advocates: We've seen Florida patients successfully overturn Revlimid denials by including detailed prior therapy timelines and NCCN guideline citations. The key is showing why alternatives failed or aren't appropriate for your specific case. External reviewers often side with patients when clinical evidence is strong.

When to Escalate Further

If external review fails, consider:

  • Filing a complaint with Florida's Office of Insurance Regulation
  • Consulting a patient advocate or attorney
  • Exploring clinical trials or compassionate use programs

Renewals: When to Reauthorize

Cigna typically approves Revlimid for 12-month periods. Start renewal 2-3 weeks before expiration:

Renewal Requirements:

  • Updated clinical notes showing response
  • Current lab results
  • Continued REMS compliance
  • Oncologist assessment of ongoing need

Specialty Pharmacy Requirements

Cigna requires Revlimid to be dispensed through their specialty pharmacy network, typically Accredo or Express Scripts.

What to Expect:

  • Automatic transfer from retail pharmacy
  • Home delivery service
  • Clinical support and monitoring
  • Coordination with manufacturer programs

Common Problems and Solutions

Problem: PA submitted but no response after 30 days Solution: Call Cigna provider services to check status and request expedited review if treatment is delayed

Problem: Denied for "not medically necessary" Solution: Request peer-to-peer review between your oncologist and Cigna medical director

Problem: Quantity limits preventing proper dosing Solution: Submit quantity limit exception with clinical justification for higher dose

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals. Our platform analyzes denial letters and creates targeted, evidence-backed responses that align with each payer's specific requirements, dramatically improving approval rates for complex specialty medications like Revlimid.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance company for personalized guidance. Coverage policies and procedures may change; verify current requirements with Cigna directly.

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